The problem of intestinal obstruction in pregnancy and puerperium is worsened by the risk it poses not just to the mother, but also to the fetus. In this review of 10 pregnant/puerperium patients the maternal mortality was 10% and fetal wastage 20%. In pregnancy and puerperium, intestinal obstruction carries a higher mortality, 10-33%, than in non-pregnant patients, 6-10%. The rarity of the problem, delay in diagnosis, anxiety over radiological examination in pregnant women, worry over laparotomy in pregnant women, all result in delay in instituting definite treatment and contribute to the morbidity. Application of established principles in the management of intestinal obstruction even when it occurs in pregnancy and puerperium might help to improve the results of management and reduce the current level of morbidity and mortality.

Courvoisier's Law is frequently interpreted as "A palpable gallbladder is a sign of malignancy". In fact, it is the most misquoted signs as he was referring to common duct obstruction by stones and other problems, without specifying malignancy ! In a retrospective study of 86 cases of distended gallbladder between 1987 and 1992, we assessed the validity and the accuracy of this law in the diagnosis of bilio-pancreatic diseases, by matching the finding of a palpable gallbladder by clinical examination (46 cases: 53%), with CT scan (75 cases: 87%), and by operative surgery (82 cases: 95%). In four cases, a palpable gallbladder spontaneously resolved before the surgical act. In 17 cases, repeated palpation of the gallbladder by several medical students or residents in one session, resulted in disappearance of the mass under the fingers of the last examiner. In 13 of these 17, a palpable gallbladder was again present after 3-7 days of its disappearance. With the new imaging technology, we may apply the implications of Courvoisier's Law to any obstruction of the distal common bile duct below the cystic duct, the ampulla of Vater, and the head of pancreas. We found this obstruction may be caused by malignancy in 87% and inflammation and lithiasis in 13%. A tumor or other obstruction above the cystic duct, will not cause distention of the gallbladder.

An incomplete picture has emerged of the complex means by which gallbladder motility is controlled under normal and pathophysiological conditions. In the first part of this review an overall account is presented. The mechanisms of cholecystokinin release, its stimulation by dietary factors and peptides elaborated by both pancreas and small intestine are discussed. The inhibition of cholecystokinin release by bile acids and proteases is also described. In the second part attention is focussed on other peptides affecting motility. These include (a) octreotide, effective for treatment of acromegaly, (b) peptide YY, contributing to a "colonic brake', (c) motilin. associated with interdigestive contractions, analogues of which possibly correct gallbladder hypomotility, and (d) substance P and calcitonin gene-related peptide, which facilitate ganglionic transmission after release from extrinsic sensory neurones and alter gallbladder responses to vagal stimulation. The sympathetic nervous system and diabetes mellitus also influence vagal responses. The former, acting presynaptically, may provide a "brake" to prevent vagal overactivity. The latter could cause hypomotility via autonomic neuropathy, although hyperglycaemia, itself, may play a role. The role of nitric oxide, released from neurones also producing vasoactive intestinal peptide is recognized. Both lengthen muscle, the former producing responses without requiring plasma membrane receptors. Gallbladder motility also changes during pregnancy and stone formation. Progesterone and cholesterol can limit G protein actions, thus impairing contractions. Inflammation is associated with abnormal motility. The production of reactive oxygen metabolites, acting directly or releasing prokinetic prostaglandins, may be responsible. It has been proposed that the gastrointestinal tract may be normally in a state of controlled inflammation, primed to react to harmful challenges.

Pediatric colonoscopy is now an established procedure to evaluate colonic disease. As there is no reports about pediatric colonoscopy in our community a retrospective study was carried in KKUH to analyze the pediatric colonoscopies. This is a retrospective study over 15 years period in KKUH to analyze the pediatric colonoscopy. Sixty-six colonoscopies were done in sixty-two patients. The age ranged from 6 month to 16 years; with 35 males and 27 females. Forty-seven of the patients were Saudi. Indication for colonoscopy were bleeding per rectum thirty-two, diarrhea ten, abdominal pain seven, ulcerative colitis in four, suspected polyps in five and other indication in seven patients. In 33 patients colonoscopy was done without premedication, 11 patient had sedation while 22 had general anesthesia. Colonoscopy revealed abnormal finding in 64%, normal findings 28.7% and due to poor preparation no endoscopic report in 7.3%. The commonest abnormal finding were ulcerative colitis in 19 patients and polyps in 17 patients. Pediatric colonoscopy is a safe, practical rewarding procedure especially in certain categories of patients mainly those suspected to have ulcerative colitis, rectal bleeding or diarrhea. A high index of suspicion of ulcerative colitis will lead to better management of patients.

Lymphoid reaction to Helicobacter pylori (H. pylori ) infection varies from simple aggregates to primary gastric lymphoma. This study analyzes various lymphoid reaction to H. pylori infection among 102 patients with dyspepsia in Bahrain during 1994-1995. Cases underwent gastroscopy for gastrointestinal complaints and at least four biopsies were taken from each patient. The prevalence of H. pylori among the study group was 79.4%. Males constituted 63.7%. Lymphoid reaction in the form of lymphoid follicles and lymphoid aggregates were found in 31.4% and 24.5% respectively. The Odds Ratio (OR) of developing lymphoid reaction among H. pylori infected cases, compared to non- H. pylori subjects was 20.1:1, and the relative risk (RR) was 7.13. The OR of developing lymphoid follicles among H. pylori cases compared to non-H. pylon subjects was 11:1 and the RR was 5.63.

Liver, a unique organ, is the only organ which has the ability to regenerate after partial hepatectomy. It can return to normal mass several weeks after 70% partial hepatectomy. The exact mechanism responsible for regeneration is yet to be known. This needs further investigation. The aim of this study is to examine the role of oxygen free radicals (OFRs) such as superoxide (0 - 2 ), hydroxyl radicals (H202 or OH - ) in liver regeneration after partial hepatectomy (<70%). To evaluate the effect of antioxidant on liver regeneration, rats were pre-treated intramuscularly with α-tocopherol (vitamin E) daily for 3 weeks, and continued for 3 weeks post partial hepatectomy (<70%) liver weight, rat body weight were determined in both control (untreated) and treated groups. The present results showed significant increase in liver weight in vitamin E treated group compared to control. The results of this paper might be useful in throwing some light on the role of oxygen free radical scavengers and antioxidants upon liver regeneration. This would have a therapeutic utilization in patients with liver problems.

Laparoscopic cholecystectomy (LC) was attempted in 847 patients, 823 (97.2%) were completed laparoscopically and 24 (2.8%) had to be converted to open cholecystectomy (OC). Acute cholecystitis was the commonest reason for conversion (13 out of 24 patients). Patients who had acute cholecystitis are five times at risk for conversion to open than other patients with non-acute cholecystitis (p<0.00I ). Age and sex were not statistically significant predictors for conversion. There were no mortalities and no major bile duct injuries in our series. These data confirms the safety of LC, identify factors which predicts conversion to OC and may be helpful in selecting patients for day care ambulatory LC.

The objective was to determine over two periods, seven years apart, the sensitivity of H. pylori isolates to metronidazole, tetracycline and erythromycin. The study periods were 1987/88 and 1995/96 and the population consisted of 133 patients undergoing upper gastrointestinal endoscopy for peptic ulcer disease in KFHU. The sensitivity of H. pylori isolates from their biopsy specimens was tested to three antibiotics using the disc diffusion method. In 1987/88, 62%, 97.0% and 98.6% of isolates were sensitive to metronidazole, erythromycin and tetracycline respectively. The corresponding sensitivities in 1995/96 were 14.5, 93.5% and 100% respectively. In 1987/88 there was no difference in the metronidazole resistant H. pylori isolates from men and women (38.2% vs 37.5%) but in 1995/96 slightly more women than men had metronidazole resistant isolates (89% vs 82.9%). The resistance of H. pylori to metronidazole increased over time. In order to improve outcome of treatment, sensitivity of H. pylori isolates needs to be determined for each patient. The recommended triple therapy requires to be modified if the prevailing sensitivity pattern of H pylori in our environment is taken into account.